Identification of potentially inappropriate cardiovascular prescriptions in the elderly using Beers criteria / Criterios de Beers en la identificación de prescripciones de uso cardiovascular potencialmente inapropiadas en ancianos

Abstract Introduction: improper use of medication is becoming more frequent and can cause physical or physiological damage. Objective: to determine the frequency of potentially inappropriate prescriptions of cardiovascular drugs according to Beers' criteria in a population of colombian patients. Method: cross-sectional study conducted during november 2016 using a population database of 326,192 adults over 65 years of age who were eligible to receive drugs included in the cardiovascular system category according to the Beers' criteria. The frequency of potentially inappropriate prescriptions was determined and investigated in relation to sociodemographic variables. Results: the mean subject age was 74.6±7.6 years (range:65-100 years). It was found that 11.3% (n=36894) of the elderly presented at least one potentially inappropriate prescription for cardiovascular conditions. The most frequent finding was the use of aspirin in patients older than 80 years of age followed by the use of prazosin for hypertension in patients over 65 years of age or in patients who consulted emergency services for syncope. The other criteria were present in less than 1% of patients, and in 16 out of 33 treatment drugs, no patients exposed to potentially inappropriate prescriptions were found. Within the criteria based on drug-drug interactions, the most frequent were loop diuretics along with prazosin (6.4%). Conclusions: the prevalence of potentially inappropriate prescriptions in an elderly population of patients in Colombia is lower than that reported worldwide. In addition, there is a need to re-evaluate the Beers' criteria in this population and adjust the guidelines according to results of pharmacovigilance of active pharmaceutical substances available in Colombia.

Resumen Introducción: el uso incorrecto de medicamentos es cada vez más frecuente y puede causar daños físicos o fisiológicos. Objetivo: determinar la frecuencia de las prescripciones de medicamentos de uso cardiovascular potencialmente inapropiadas según criterios de Beers en una población de pacientes colombianos. Métodos: estudio de corte transversal, a partir de una base de datos de una población de 326.192 adultos mayores de 65 años, durante el mes de noviembre de 2016, susceptibles de recibir medicamentos incluidos en los criterios de Beers en la categoría de sistema cardiovascular, determinando la frecuencia de prescripciones potencialmente inapropiadas, así como la identificación de variables sociodemográficas. Resultados: la edad promedio fue de 74,6±7,6 años (rango 65-100 años). Se halló que el 11,3% (n=36894) de los ancianos tuvo al menos una prescripción potencialmente inapropiada para condiciones cardiovasculares. El criterio más frecuente fue el uso de aspirina en mayores de 80 años, seguido del empleo de prazosín para la hipertensión arterial en mayores de 65 años, o en pacientes que consultaron por síncope a los servicios de urgencias. Los demás criterios se presentaban en menos del 1% de pacientes y en 16 de 33 fármacos de cuidado no se halló ningún paciente expuesto. Entre los criterios basados en interacciones fármaco-fármaco, el más frecuente fue diuréticos de asa junto con prazosín (6,4%). Conclusiones: la prevalencia de prescripciones potencialmente inapropiadas en una población de ancianos colombianos es menor a la reportada en el mundo. Además, se plantea la necesidad de reevaluar los criterios de Beers en dicha población y ajustarlos de acuerdo con los informes de farmacovigilancia y principios activos disponibles en Colombia.

Enfermedad de Kawasaki. Reporte de un caso infrecuente en el adulto / Kawasaki disease. Report of a rare case in an adult

RESUMEN La enfermedad de Kawasaki forma parte de un grupo heterogéneo de afecciones de baja frecuencia que se caracterizan por la presencia de inflamación y necrosis de la pared vascular, que generan diversas manifestaciones clínicas y patológicas, las cuales comprometen medianos vasos, y que afectan principalmente a la población pediátrica. Presentamos el caso de un hombre de 36 arios de edad, sin antecedentes patológicos previos, con cuadro febril de 4 días de evolución asociado a cefalea, náuseas y odinofagia, con posterior aparición de múltiples lesiones maculopapulares generalizadas, las cuales se resolvieron con descamación en pulpejos, palmas y plantas. Se documenta conjuntivitis no supurativa bilateral, además de compromiso de la mucosa oral y los labios. La biopsia de piel reportó vasculitis linfocítica asociada a compromiso renal, hepático y cardiaco (miocardiopatía dilatada con fracción de eyección deprimida); se configuró el diagnóstico de enfermedad de Kawasaki completa del adulto con manifestaciones atípicas. Recibió tratamiento con metilprednisolona, ácido acetilsalicílico 100mg/día, una dosis única de inmunoglobulina IgG intravenosa 2 g/kg y terapia dialítica interdiaria, logrando una recuperación completa.

ABSTRACT Kawasaki disease is part of a heterogeneous group of low frequency diseases that are characterized by the presence of inflammation and necrosis of the vascular wall, generating various clinical and pathological manifestations, which compromise medium vessels, and mainly affecting the pediatric population. The case is presented of a 36-year-old man with no relevant past medical history, with a febrile episode of 4 days of onset, together with headache, nausea, and odynophagia with subsequent onset of multiple generalized maculopapular lesions. These resolved with subsequent desquamation of fingers, palms and soles of feet. Non-suppurative bilateral conjunctivitis is documented, as well as involvement of oral mucosa and lips. Skin biopsy reported lymphocytic vasculitis, associated with renal, hepatic and cardiac involvement (dilated cardiomyopathy with depressed ejection fraction). A diagnosis of complete adult Kawasaki disease with atypical manifestations was established. He was treated with methylprednisolone, acetylsalicylic acid 100 mg per day, and a single dose of intravenous IgG immunoglobulin 2 g/kg, and daily dialysis therapy to achieve complete recovery.

Factors related to excessive polypharmacy (≥15 medications) in an outpatient population from Colombia.

AIMS: To determine the frequency of excessive polypharmacy (≥15 medications) in an outpatient population from Colombia and the variables associated with this condition. METHODS: A cross-sectional study using a systematised database of 6.2 million affiliates of the Colombian Health System. All patients treated uninterruptedly with 15 or more medications for 3 months (January-March 2017) were included. Sociodemographic, pharmacological, potential drug interactions, and prescribers' variables were identified. RESULTS: A total of 264 patients with prescriptions of ≥15 medications were identified; with an estimated prevalence of excessive polypharmacy of 108.4 per 100 000 people. The mean age was 67.7 ± 17.8 years and 60.6% were females. The mean number of medications per patient was 20.1 ± 4.5 and 48.9% (n = 129) had 20 or more. The most used were antiulcer medications (89.0%; n = 235), antihypertensives (85.6%; n = 226), analgesic/antipyretic (80.3%; n = 212), psychiatric/neurologic medications (78.5%; n = 207), statins (67.4%; n = 178), acetylsalicylic acid (59.5%; n = 157), and vitamins (57.2%; n = 151). On average, each patient had 21.0 ± 11.4 drug-drug interactions and were attended by 6.2 ± 3.1 physicians. Being treated by seven or more physicians (OR: 5.09; 95% CI: 1.64-15.79) increased the probability of receiving more than 20 medications. CONCLUSIONS: Drugs for treatment of chronic conditions prevailed, especially in elderly patients with multiple chronic conditions; however, some groups of medications without clear indications, such as antiulcer medications or vitamin supplements, also had extensive use. A main factor that increases the probability of polypharmacy greater than 20 drugs is care by seven or more physicians, which shows a fragmentation in patient care by the country's health system, without achieving co-ordination and integration between the different agents involved in medical care, also influenced by different physicians' practice patterns.

Drugs With Anticholinergic Potential and Risk of Falls With Hip Fracture in the Elderly Patients: A Case-Control Study.

BACKGROUND/OBJECTIVE: To determine the association between the use of anticholinergic drugs and the risk of falls with hip fracture in a population older than 60 years. METHODS: A case-control study in patients older than 60 years with a diagnosis of hip fracture. All drugs dispensed during the previous 30 days were identified. Sociodemographic, clinical, pharmacological (drugs according to the Anticholinergic Risk Scale [ARS]), and polypharmacy variables were analyzed. MEASUREMENTS: Falls with hip fracture and type of drug according to the ARS. RESULTS: A total of 300 patients with hip fracture and 600 controls were included. The mean age was 81.6 ± 8.9 years, with female predominance (71.3%). The use of drugs with moderate (odds ratio [OR]: 1.97, 95% confidence interval [CI]: 1.19-3.27) or high ARS scores (OR: 1.83, 95% CI: 1.13-2.96) increased the probability of fracture. CONCLUSIONS: There was an association between the use of drugs with anticholinergic properties and the probability of hip fracture in elderly patients and it was possible to establish the level of risk.

Association between the use of benzodiazepines and opioids with the risk of falls and hip fractures in older adults.

ABSTRACTBackground:To determine the association between the use of opioids and benzodiazepines and the risk of falls with hip fracture in populations older than 65 years in Colombia. METHODS: A case-control study with patients older than 65 years with diagnosis of hip fracture. Two controls were obtained per case. The drugs dispensed in the previous 30 days were identified. Sociodemographic, diagnostic, pharmacological (opioids and benzodiazepines), and polypharmacy variables were analyzed. A logistic regression model was used to analyze the risk of fall with hip fracture while using these drugs. RESULTS: We included 287 patients with hip fractures and 574 controls. There was a female predominance (72.1%) and a mean age of 82.4 ± 8.0 years. Of the patients, 12.7% had been prescribed with opioids and 4.2% with benzodiazepines in the previous month. The adjusted multivariate analysis found that using opioids (OR:4.49; 95%CI:2.72-7.42) and benzodiazepines (OR:3.73; 95%CI:1.60-8.70) in the month prior to the event was significantly associated with a greater probability of suffering a fall with hip fracture. CONCLUSIONS: People who are taking opioids and benzodiazepines have increased risk for hip fracture in Colombia. Strategies to educate physicians regarding the pharmacology of older adults should be strengthened.

Síndrome serotoninérgico en anciano con falla renal crónica tratada con linezolid: reporte de caso / Serotonin syndrome in an old man with chronic kidney disease treated with linezolid: Case report

El síndrome serotoninérgico es una reacción adversa y potencialmente mortal a medicamentos; está caracterizado por cambios en el estado mental, hiperactividad autonómica y anormalidades músculo-esqueléticas causadas por exceso de serotonina a nivel central. Se reporta el caso de un paciente de 71 años con enfermedad renal crónica estadio V y cuadro clínico de infección intraabdominal asociada al catéter. Luego de 33 días de la hospitalización presentó temblor en manos, hiperreflexia y taquicardia. Al día 36 se tornó confuso, desorientado e incoherente, con palpitaciones y disneico. Entre los factores de riesgo para desarrollo de síndrome serotoninérgico se encuentra el uso de linezolid, que en combinación de otros medicamentos con acción serotoninérgica -como los inhibidores selectivos de recaptación de serotonina, el litio, la trazodona, entre otros- se asocia con la presentación de este cuadro. El síndrome serotoninérgico puede ser evitado con una buena educación al personal médico y la modificación de las conductas de prescripción de medicamentos; el pilar del tratamiento se basa en la suspensión de los fármacos que están causando el cuadro y el planteamiento de medidas de soporte.

Serotonin syndrome is a potentially fatal adverse reaction to medication. It is described as a clinical entity characterized by changes in mental status, autonomic hyperactivity and musculoskeletal abnormalities caused by excess of serotonin at the central nervous system. A 71 years old patient with history of stage V of chronic kidney disease with clinical symptoms of intraabdominal infection associated with catheter is reported. After 33 days of hospitalization the patient began to show hand tremor, tachycardia and hyperreflexia. On day 36, the patient became confused, disoriented and incoherent, dyspneic and with palpitations. Linezolid in combination with others drugs with serotoninergic action -such as selective serotonin reuptake inhibitors, litium, trazodone and others- has been associated with serotonin syndrome presentation. Serotonin syndrome can be avoided through a combination of medical staff education and the modification of prescription drugs behavior. The mainstay of treatment is based on the suspension of drugs that cause the symptoms and the proposal of support measures.

Anticholinergic Risk and Frequency of Anticholinergic Drug Prescriptions in a Population Older Than 65.

OBJECTIVE: To determine the risk and frequency of anticholinergic drug prescriptions in a population affiliated with the Colombian General System of Social Security in Health. DESIGN: A cross-sectional study was conducted in 2013. PARTICIPANTS: Patients older than 65 years who received drugs with the potential to block cholinergic receptors, in accordance with an anticholinergic risk scale. MEASUREMENTS: The total anticholinergic load was determined by the sum of the risk of each prescribed drug. RESULTS: The study included a total of 27,654 patients with a mean age of 76.1 ± 7.6 years, and 61.9% were women. A total of 9.1% of the population older than 65 years had received a prescription of at least one of these drugs, and the prevalence of these prescriptions was 112.5 per 1000 members. The average number of drugs prescribed per patient was 1.4, and the drugs most frequently prescribed contained trazodone, methocarbamol, and loratadine. Being prescribed by practitioners of surgical or related specialties was the only variable significantly associated with prescriptions with high anticholinergic risk in the multivariate analysis (odds ratio 1.61; 95% confidence interval 1.335-1.934; P < .001). CONCLUSION: We found a high frequency of prescription medications with some degree of anticholinergic load, and in almost half of the patients, the anticholinergic risk score was very high. The prevalence of prescription of these drugs falls in the range of that reported globally. It is essential to educate prescribers about the risk to their patients.